1. Introduction This report analyses the data collated from the Domiciliary Medicine Use Review conducted by the Medicines Management and Pharmacy Team as part of Southwark’s Partnership for Older People’s Project (POPP). The Medicines Management and Pharmacy Team’s objectives in the POPP project were:• To support and ensure patients are able to use their medicines effectively and
• To improve patient, carer and care workers involvement with medicines use
• To have a consistent point of referral to suitably trained pharmacists (e.g. MUR
accredited Community Pharmacists (CP) or Specialist Pharmacists) to identify older peoples’ medicine management needs and enable safe and appropriate use of medicines
• To ensure collaborative working with other health and social care professionals in
the community and acute trusts so that older people receive coordinated care in their homes or when moving between different care settings.
The purpose of this review is to explore older people’s experiences of managing their medicines in the community and to help improve medicines management & pharmacy support to enable vulnerable older people to use their medicines appropriately and safely. It attempts to assess older people’s capacity to manage their medicines, identify possible barriers to self-administration and assess how people overcome these barriers. In addition to collecting data, the pharmacists conducting the reviews provided support and solutions in collaboration with other health and social care professionals and organisations for problems identified. These actions were also recorded and are analysed in this report. The Medicines Management and Pharmacy Team worked with the Southwark POPPs evaluator to design a new tool to conduct this review. Existing Medication Review and Medicines Use Review (MUR) templates used by GPs and CPs were considered inadequate for this purpose. This tool is attached below as Appendix 2. Patient selectionThe reviews were conducted between July 2007 and March 2008 by three primary care pharmacists. Data were collected from 48 patients. Referrals came mostly from GP practices, the monthly POPP Multidisciplinary Meetings (MDMs) and the Community Consultant Geriatrician. The average age of patients reviewed was 79. The criteria for selection were that they are over 65 and living independently at home. The time taken to complete the MUR was recorded in 21 of the 49 cases. The average time recorded for these 21 cases was 44 minutes. However, this is unlikely to include the travelling time to and from the patient’s home in all cases. 2. Adverse Drug Reactions Patients were assessed for adverse reactions from the drugs they are using. In 85% of cases no known Adverse Drug Reactions (ADR) were recorded. Table 1 shows those reactions recorded. (Some patients recorded more than one ADR). Known drug allergies are recorded in Table 2. Table 1: Adverse Drug Reactions None known
Dizziness, Falls, resulting in hospital admission
Table 2: Known allergies/sensitivities No known drug allergies
Penicillin 2 Amitriptylline/simvastation 1 Cefuroxime and metronidazole
3. Medical History Issues Patients’ medical history was identified from discussions with the patients, types of medication seen in the home and District Nurse’s or Community Matron’s records. A total of 181 medical history issues were recorded, an average of 3.7 per patient. (The form has the capacity to record up to 7 medical history issues per patient.) Table 3 shows the most commonly recorded issues and the percentage of patients experiencing them. A full list of conditions is supplied in Appendix 1. Table 3: Most common medical history issues Number % of patients with Medical History Issue recorded issue 4. Details on medication

Number of medications prescribed A total of 407 prescribed medicines, an average of 8.3 per patient, were recorded. Chart 1 shows a breakdown of the numbers of medicine per patient with 36% on between 6 and 10 medications and a further 28% on between 11 and 15. Chart 1: Breakdown of number of medicines per patient

In addition a total of 19 non-prescribed medicines were being taken by patients. Prescribed medicines not taken The MUR recorded a total of 18 prescribed medicines, or 4%, that were not being taken by the patient. Medicines taken away Medicines were taken away from 11 patients, or 22% of the total patients reviewed. In total, 80 medicines were taken away. However, it is important to note that 44 of these medicines were taken from one patient. Precise details of medicines taken away were recorded for eight patients. Table 4 lists these. Table 4: Medicines taken away as a result of MUR Aspirin 75mg tablets Clopidogrel 75mg & Dexiibuptofen tabletsDypirridamol capsules 200mg x120 Gabapentin caps 300mgx212,Fybogel orange Sachets x20, Simvastatin 40mg x35, Alfacalcidol 1mcg x24 Haloperidol 500mcg caps (x20) Indapamide 2.5mg tablets, paracetamol tabs, Co-fluampicillin caps, Co-proxamol tabs Flixotide Inhaler The cost of medicines taken away was recorded for 6 of these patients. The cost ranged from 75p to £86. The small number recorded makes a cost effectiveness analysis unreliable for this review. 5. The administration of medicine In 41% of cases, medicines are self-administered and in a further 9% they are self-administered with the help of a family member. In 13% of cases an agency carer is involved in administration. Table 5 provides a full breakdown. Table 5: Who administers medicines Self-administered 19

Where a family member was involved in administration, the MUR explored the type of help provided. These are laid out in Table 6. Table 6: Type of help given by family members Prompts

The MUR asked a question exploring the type of agency carer involvement in administration. Out of the seven cases where these details are recorded, the agency carer administers the medicine in four cases and leaves the medicine out for the patient to take themselves in three cases.

Barriers to self-administration The MUR explored the extent and the different types of barriers to self-administration of medicines among patients. Table 7 shows that 65% of patients had some type of barrier to self-administration. 42% had cognitive barriers, 10% had sensory barriers and 38% had physical barriers.

Table 7: Types of barriers to self-administration Barriers to self-administration
Are there cognitive barriers to self-administration?
Are there sensory barriers to self-administration?
Are there physical barriers to self-administration?
Table 8 breaks down the cognitive barriers recorded in the MUR, with the majority relating to confusion or forgetfulness. Table 9 breaks down the physical barriers. Table 8: Types of cognitive barriers to self-administration Confusion or forgetfulness
Alzheimer's 3 Dementia 1 Lack of motivation
Stroke 1 Table 9: Types of physical barriers to self-administration
Housebound due to poor mobility & co-morbidities. Unable to perform routine daily activities
All five of the sensory barriers recorded were eyesight-related with some saying they have difficulty reading small print. The MUR measured whether there were other barriers to self-administration not picked up in the above three categories. These are laid out in Table 10. Table 10: Other barriers to self-administration Doesn't understand medication
Motivation to take medicines has increased
Patient can't always match medicine name to condition 1 Patient needs constant supervision in all areas of care
The type of Multiple Compartment Aid (MCA) used to administer medicines was recorded in 33 cases. As Table 11 shows, the most popular mode was blister packs supplied by community pharmacists. These aids are non-NHS funded. Some of other aids were provided by the PCT through District Nurses and some were purchased and filled by patients. Table 11: Multiple Compartment Aid used to administer medicine

Type of MCA Number Percentage
Medicates from original packs (manufacturers)
Original containers (pharmacy containers)
The MUR form asks who fills these MCAs. In all 21 cases where the answer was recorded, the MCA is filled by the community pharmacist. 6. Medicine Use Issues In addition to filling in the headline data analysed above, the reviewers explored in more depth patients’ use of medicines and identified the nature of barriers to self-administration and what was done to address them. The answers they provided were recorded in free text. This section of the report analyses this text to show the different types of issues encountered, the actions planned to address these issues and, where recorded, the outcomes of actions taken. Asked to rank whether the priority for addressing these issues were high, medium or low, 41 (51%) of the 80 issues recorded were classed as high priority. The issues identified were varied but the analysis identified three recurring themes as follows:
Difficulty using medicines due to cognitive, physical or sensory barriers
The analysis is organised under these three themes. 6.1 Inappropriate use of medicines There were several cases where the reviewer believed the existing use of medicines was inappropriate. Inadequate pain control (9 cases) The most common concern identified was perceived inadequate pain control, which was experienced by 20% of patients. In some cases the reviewer helped to resolve these issues by discussing and agreeing changes with the patient and their GP and counselling the patients on the appropriate and safe use of analgesics and potential side effects. In one case the reviewer counselled the patient on safely increasing their painkillers from four to eight per day and how to deal with side effects. In another case
increased doses of dihydrocodeine with paracetomol were agreed. Another patient taking co-dydramol for pain that was inadequately controlled had the dosing and the timing of the medication changed and was counselled on bowel management as a result of increased dose. Another patient complained of constant mild pain but had ran out of analgesia and said that Cocodamol makes her drowsy and confused. The reviewer discussed this with the GP who agreed to prescribe paracetamol. In another case the reviewer provided advice on pain management to a patient with ulcers (pain-free at the moment) about pain management in the future. In other cases, the reviewer’s attempts to address pain control were less successful. One patient was experiencing pain when being transferred to a commode but the reviewer’s recommendations to increase paracetamol intake to four times a day was not welcomed by the patient. Another taking co-dydramol was discovered to be receiving only two doses at night, leaving her without pain relief most of the day. The reviewer attempted to discuss pain relief but this was difficult as the patient’s husband felt this would be contrary to doctors’ instructions. The reviewer referred the patient and spouse to a pain clinic. Another patient complained that ibuprofen was not providing adequate pain relief. The reviewer informed the patient’s GP who promised to review the case but felt that the patient was already on enough pain relief
The time of administration inappropriate (1 case) A patient complaining of gastric acid was taking medicine (lansoprazole) at the wrong time of the day. This was changed to later in the day to ensure effective relief at times when the symptoms were worse and was advised to take an additional medicine (gaviscon) if the symptoms continued. Concerns over potential side effects (6 cases) Possible side effects of medicines were discovered for a number of patients. In one case the use of oxygen caused a very dry nose for a patient. Sodium Chloride nasal drops were suggested by the reviewer as an alternative and a referral to a respiratory nurse was made. This resulted in the prescription of a facemask and humidifier through the GP. Another patient complained of dry, irritated eyes. The reviewer suspected Hydroxycholoroquine may be causing ocular toxicity for this patient and the GP was informed in order to review the patient’s need for an eye test. In another case, Simvastatin was thought to be causing hot flushes and insomnia and the patient decided to take this medicine earlier in the evening following the advice of the reviewer. In another three cases, concerns on side effects were raised but the outcome was not recorded in the review form. A patient reported an allergy to one of two medicines and the reviewer arranged to speak to the patient’s daughter to investigate further. Another patient was discovered to have increased urinary frequency possibly as a result of bumetanide tablets, a diuretic. The reviewer planned to explore the possible reduction of bumetanide with GP and a social work assessment for a commode. Another reviewer had concerns over the drug Piroxicam used by a patient, which has reports of increased risk of skin reactions. The reviewer referred the patient to their GP for a medication review.
Lack of clarity on what medicines to use (2 cases) In some cases the reviewer discovered confusion as to what medicines were in use. In one case, the reviewer discovered that Donepezil was increased from 5mg to 10mg by the patient’s hospital consultant but written instructions were not provided as required for District nurses to administer the new dose. The reviewer advised the patient’s daughter to contact the patient’s clinic to fax through instructions to the GP and nurse. In another case a patient with swollen ankles stated that their “water tablet” was no longer making her go to toilet but the reviewer noted there was no such medication in the blister pack. This was discussed with the GP. Lack of understanding on purpose of medicines (4 cases) Some patients showed a poor understanding of the purpose of their medication. One patient did not understand why his dose of statin was increased (from 20mg of atorvastatin to 40mg of simvastatin.). The reviewer explained that different drugs have different potencies and absorption rates and that both of these doses had about the same effect. The patient was satisfied with this explanation. Another showed a lack of understanding regarding warfarin therapy and the reviewer counselled the patient and spouse to increase their understanding. Fear of taking medicine (2 cases) Some patients were fearful of taking their prescribed medicines. One patient was unwilling to take enalapril due to fears of over-medication. The patient’s sister was on multiple medications and became very unwell. The reviewer discussed these fears and reassured her of the drug’s safety. Another patient was prescribed haloperidol for nausea but was not taking it as the accompanying leaflet refers to it being an 'antipsychotic'. The reviewer counselled the patient that haloperidol can be used safely for nausea, but usually in severe cases. Alternatives were discussed with the patient and GP and metoclopramide was prescribed instead. Medicine prescribed suspected inappropriate for patient’s needs (5 cases) In some cases, the medicines prescribed were suspected by the reviewer to be inappropriate for patients. One patient was taking a drug (Clopidogrel, with potential side effects of gastric ulcers and bleeding) for nine months, which should have been stopped after one month. The reviewer discussed this with the GP and the medicine was stopped and Paracetamol prescribed. The patient’s spouse was informed and a record of medication and times to be taken were provided in a reminder card. Another reviewer thought that a patient taking salbutamol four times a day should have their dose increased to six to eight times a day in order to control symptoms of breathlessness. Another thought some of the patient’s medicines needed to be stopped (Dypyridamole) and referred this to the GP for review. However, in these two cases the outcome was not recorded. In another two cases the patients’ GP responded that their patients’ medication was appropriate. One patient’s dose of Ramipril seemed to be inappropriate to the reviewer but the GP confirmed that it was safe to continue with this dose. Another reviewer thought that a patient that may have required an increased use of insulin to control high blood glucose levels in the evenings and to control neuropathy in their feet. The GP disagreed, believing that the insulin dose was adequate. Different methods of administration required (3 cases) In some cases the method of administering medicine was thought to be inadequate by the reviewer. One patient was unable to use their salbutamol easibreathe (breath activated) inhaler due to poor inspiration. The reviewer discussed alternative devices with the patient and GP. The GP was unsure why the patient was on salbutamol and agreed to review whether it was required. Two patients had problems with a
medication in tablet form and as a result of the review, this was changed to liquid form. Inappropriate mode of dispensing (4 cases) Some patients were discovered to be having problems using Multicompartment Compliant Aids (MCAs) such as a dosette box. One patient had Adcal D3 chewable tablets that were unsuitable for a dosette box. The community pharmacist was informed and it was agreed to dispense in original containers or dispensing container. In another case the reviewer arranged a second visit through the patient’s GP to work with the patient and ensure it was better accepted. One patient’s son requested that the patient’s medicines be dispensed in blister packs, following a social worker’s advice. However, district nurses require medicines to be administered in pharmacist dispensed and labelled containers. The reviewer agreed with the community pharmacist, patient’s son and district nurse that medicines would be dispensed in original packs and pharmacy containers. In another case a reviewer was informed that a care agency’s policy is for carers to only administer medicines from a dossete box or blister pack. This was considered poor practice by the reviewer and the issue was discussed with the social services commissioner. Medicines needed were not being supplied or administered (5 cases) Medicines that should have been available according to prescriptions were found in some cases not to be available. In two cases an inhaler needed was not included on the repeat prescription and the reviewer contacted the patients’ GPs in both cases to rectify this. One patient was discovered to be getting an inadequate supply of medicine on their repeat prescription (100 tablets of co-codamol instead of 224), which led to inadequate pain control. The reviewer contacted the GP to confirm and change quantities on repeat prescription. In another case eye drops that should have been administered by a district nurse in the evening were being missed. The reviewer recommended and agreed with the patient’s daughter to purchase an autodrop device for easy self-administration. Further treatment thought to be needed (4 cases) In some cases the reviewer thought that additional medicines might be needed. One patient had wheezing and breathing difficulties and difficulty bringing up phlegm. The reviewer arranged with the patient’s GP to prescribe sodium chloride nebulising solution for relief (in addition to the current prescription for carbocysteine). Another patient’s blood pressure was found to be very varied over a 3 month period and the reviewer informed the patient’s GP, who agreed to review it. One patient at high risk of osteoporosis was identified as needing bone health medication. The patient does not like to chew tablets so the reviewer recommended a Bisphonate and this was communicated to the patient’s GP. In a care home another patient was discovered not to have been seen by a GP since admission and the reviewer arranged for the GP to review the patient and test Thyroxine levels. Medicines previously prescribed that should have been discontinued (4 cases) In some cases, prescription medicines that had been stopped were available to the patient. One patient was discovered to be using prochlorperazine and flupentixol although this hadn't been prescribed for several months. The reviewer referred this to the patient's GP for review. For another patient a supply of folic acid tablets probably prescribed whilst on methotrexate was found and presumed was no longer needed. In another case the reviewer recognised that quantities of tramadol were more than required. They were prescribed for regular use while the patient had decided to take it only once a day when she felt she needed it. The patients medication was being dispensed from a dossete box into a small cup by carers. Various capsules and tablets were found daily on the floor and in the bed by care workers. Discussions with
the GP resulted in the reduction of the dose from 100mg three times daily to 100mg daily when required for pain.

6.2 Difficulty using medicines due to cognitive, physical or sensory barriers Forgetfulness and confusion (6 cases) Patient confusion and forgetfulness is a common problem identified in this review. One patient had difficulty remembering when to take their medication. The reviewer helped the patient complete a medication information card which listed all medicines and when to take them. Another patient who sleeps irregular hours became confused having to adjust the times she takes medication and antibiotics. The reviewer discussed the options for timing with the patient and stopped co-proxamol, paracetamol and indapamide due to a duplication of therapy and potential to overdose. Another patient was forgetting to take an important antibiotic that was not in their dossette box. The reviewer counselled the patient and daughter on the importance of taking the antibiotic and provided a medical information chart for them. The patient’s daughter agreed to discuss this with the agency carers involved in administering medicine. In another case the patient’s carer was forgetting to prompt medication that was not in the dosette box (Adcal and analgesia). The reviewer counselled both the patient and carer on appropriate use of medication and supplied a medication information card that highlighted what medicines were in and out of the blister pack. The reviewer found paracetomol and co-codanol in another patient’s cupboards home, taken for occasional relief of pain. The patient said co-codanol helped relieve pain more without dizziness and the paracetomol was ineffective. The reviewer removed the paracetomol given the confused and forgetful nature of the patient. Physical barriers (3 cases) One patient was discovered to have poor Inhaler technique due to the limited use of their left arm. The reviewer arranged for the use of an aerochamber and mask with the community matron and their GP. Another patient was unable to press down on their inhaler canister and also had a poor understanding of how inhalers worked. The reviewer counselled the patient and arranged with the GP and community pharmacist to supply a breath-activated inhaler. One patient was unable to access medicines in child proof containers so the reviewer arranged with the patient’s community pharmacist to use ordinary screw caps. Eyesight (1 case) One patient with poor eyesight was best able to identify medication through the colour of packaging. The reviewer agreed with the community pharmacist to supply medication from the same manufacturer to ensure consistent colours.

6.3. Delivery of dispensed medicines (8 cases) Mobility problems prevent many patients from collecting their prescriptions and dispensed medication from GP surgery and pharmacy Many people have friends or family who collect medicines for them. In some cases this works well. For example one patient with mobility problems whose friend collects for her was informed by the reviewer of a delivery service if problems are encountered in the future. Another patient unable to collect their medicines was likely to be going to a care home and the niece was happy to pick up medicines in the meantime.
However, for some cases encountered in the review, arrangements were not satisfactory. In one case arrangements to have medicines delivered by a friend were unreliable, in some cases leading to medication being missed. As the usual community pharmacist did not provide a delivery service, the reviewer recommended a change in the care package to include medication collection from the pharmacy. Another patient’s niece was no longer able to help with medicine for much longer so the reviewer again arranged for medication administration to be included in the patient’s care package. Another patient’s spouse had difficulty collecting the patient’s medicines due to a prosthetic leg and needed to use a taxi. The reviewer advised the patient to discuss delivery with their community pharmacy. In another case it was discovered nurses were unable to gain access to the home to dispense medication and the reviewer made arrangement to contact a neighbour who had a key to gain access. One patient had difficulty getting repeat prescriptions from their GP and medicines from the pharmacist while another was down to one week’s supply of medicine and anxious about running out. In both cases the reviewer facilitated a repeat prescription collection service with the patient’s GP and community pharmacist. Timing of dispensing inconveniencing patients In some cases the method of dispensing medicine was causing inconvenience to the patient. One patient had quantities of medicines on repeat prescription resulting in the patient’s spouse collecting medicines at several times a month. One patient received only two weeks supply of cocodamol at a time for pain control after knee operations but received a two-month supply of nitrazepam. The patient had to buy additional cocodamol from the pharmacy until her next repeat prescription was due. In both cases the reviewer contacted the GP to arrange to synchronise dispensing. 7. Conclusions This analysis provides a profile of medicine use for a sample of older people in the community and illustrates the nature of the problems experienced by that sample around medicines management. This indicates that many of the issues highlighted here are replicated across the population of older people in Southwark. It shows that many of the problems encountered are avoidable and amenable to relatively simple solutions that take into account the living circumstances and available support networks of patients. It also indicates the potential benefits of a proactive approach to medicines management in older people with long-term conditions, especially those who are housebound or have limited mobility. Medicines Management & Pharmacy comments on the MUR analysis The Medicines Management & Pharmacy team have added the following commentary to this report. The Medicines Management & Pharmacy team’s involvement in the Partnership for Older People Project and the results of this MUR show that a cross-sector referral system is needed to ensure safe and consistent medicines management and pharmacy support to vulnerable older people. Medicines management needs to be fully integrated into the Single Assessment Process (SAP) and assessments for Long-term Conditions (LTC) across social and healthcare organisations to ensure continuity, consistency, a whole systems
approach to care and to reduce duplication. It should include the establishment of a formal referral process to resolve medicines issues especially where needs are still unmet. The system should be accessible to and understood by all health and social care professionals, patients and carers. There is a need for a consistent assessment tool for use across health care and social care professionals and care providers in assessing medicines management needs and identifying appropriate referral. Providers of social care need to understand that medicines management support is an integral part of packages of care. All health and social care professionals need to understand how the community pharmacy contract has been implemented locally and how community pharmacists can support patients within the framework of the contract. Clear lines of accountability are needed for all commissioned services, whether through health or social care, with defined medicines management quality indicators for monitoring of service provision within service level agreements. Southwark Health and Social care has developed safe principles to support care workers in the safe administration of medicines to patients. About 150 care workers were trained and expected to directly administer medicines in order to reduce some of the issues highlighted above. However the pilot identified that some care agencies who had signed up to these principles were not supporting medicines administration. This issue needs to be addressed.
Appendix 1 – Full list of Medical History Issues recorded

Number patients Medical History Issue recorded with
Peripheral Vascular Disease - associated with pain
Appendix 2 – Medicine Use Review Form

Partnership for Older People Project
Source of referral: POPP MDT Meeting GP Practice
Community Geriatrician - Complex Care Hospital readmissions
Lomond House Continuing Care Assessments
Visit details Pharmacist conducting review
Pharmacist signature Pharmacist accompanied on visit by:
Social Worker District Nurse Community Matron
Recording of patients’ informed consent
To evaluate this MUR it is useful to see how often the patient attended A&E or was admitted to hospital, why they were admitted and how long they stayed. To
do this we need the patient’s agreement to use their NHS number. Does the patient agree to let us use their NHS number?
Health data Significant previous Adverse Drug
Medical History as described by patient and from information recorded in

Medical History Issue 1 Medical History Issue 2
Medical History Issue 3 Medical History Issue 4
Medical History Issue 5 Medical History Issue 6 Medical History Issue 7
Who is monitoring these health problems/health issues? Details on medication
How many medicines are prescribed at beginning of review? How many of the prescribed medicines are not being taken? How many non-prescribed medicines are being taken? How many medicines were taken away by reviewer? What medicines were taken away?

How many medicines are prescribed at end of review?
Are there any barriers preventing the patient from self-administering their medicines? Yes
Yes No Are there sensory barriers to self-
Yes No Are there physical barriers to self-
Yes No Are there other barriers to self-
Family/carer input into administration of medicine (i.e. not agency care worker)
Care workers input into administration of medicine
Is there a care package/paid care for the patient?
Does the agency carer have input into administering medicine?
If ‘Yes’ is the agency carer prompting Briefly describe how they help or administering
Details of Multi Compartment Aid (MCA) (if applicable)
What type of MCA is in use? Blister pack
Medimax Other – please state Who fills the MCA?
Solutions discussed and agreed with patient/carer What solutions to medicine issues were discussed?
Medicines Use Issue Priority Proposed action Action by Outcome if known with dates
Who were solutions to barriers discussed with throughout this review?
Patient and family member Were solutions discussed with agency carer? (if applicable) Yes No Are there any issues thrown up by this review not addressed by this form ?
General Practitioner

Baxter International Inc. One Baxter Parkway FOR IMMEDIATE RELEASE Media Contacts: Kirsty Langton 01635 206513 BAXTER AND ITS FOUNDATION EXPAND ACCESS TO HEALTHCARE AND EDUCATION THROUGH 2009 CONTRIBUTIONS Company Recognised for its Sustainability Efforts DEERFIELD, Ill., March 18, 2010 – Baxter International Inc., its employees and The Baxter International Foundati